Chronic Insomnia Disorder Is Among Should Take Measures to Discuss Sleep the Most Widely Reported Clinical Con- Problems and Their Impact on The
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Review Article Address correspondence to Dr Alon Y. Avidan, University of California Los Angeles, Chronic Insomnia David Geffen School of Medicine, Reed Neurological Research Center, 710 Disorder Westwood Blvd, C153, Los Angeles, CA 90095-1769, [email protected]. Alon Y. Avidan, MD, MPH, FAAN; David N. Neubauer, MD Relationship Disclosure: Dr Avidan has received personal compensation for ABSTRACT serving as a speaker for Arbor Pharmaceuticals and PERNIX Purpose of Review: Neurologists, along with all health care providers, commonly Therapeutics and receives encounter patients with insomnia, which is a condition that impacts patients’ royalties from Elsevier and underlying neurologic conditions in a bidirectional manner. While chronic insomnia UpToDate, Inc. Dr Neubauer has received personal is one of the most common sleep disturbances, only a small proportion of individuals compensation for serving on with this condition discuss their sleep problems with their providers. When insomnia is the board of directors for the described, it is more often in relationship to another medical problem, as opposed to National Sleep Foundation, as a consultant for Purdue an independent condition. In neurology practice, multiple factors including pain, Pharma LP, and as a lecturer movement disorders, sleep apnea, and medications that act on the central nervous for the American Academy of system often contribute to insomnia. An all-inclusive approach is necessary when Sleep Medicine, the American College of Chest Physicians, evaluating sleep problems in patients with insomnia. the Clayton Sleep Institute, the Recent Findings: The US Food and Drug Administration (FDA) has approved several New Jersey Sleep Society, and medications for the treatment of insomnia that target specific receptor systems in the the US Psychiatric and Mental Health Congress. brain and incorporate several unique pharmacodynamic and pharmacokinetic profiles Unlabeled Use of that can represent customized therapy for specific insomnia phenotypes. FDA-approved Products/Investigational medications for insomnia include +-aminobutyric acid (GABA)-modulating benzodiaz- Use Disclosure: epine receptor agonists, a melatonin receptor agonist, a histamine receptor antagonist, Drs Avidan and Neubauer discuss the off-label uses of and the newest approved option, a hypocretin (orexin) receptor antagonist. various central nervous Summary: This article provides an evidence-based multidisciplinary approach to the Y system acting medications treatment of insomnia, highlighting the rationale and utility of cognitive-behavioral for insomnia, which include sedating antidepressants such therapy and pharmacologic interventions. Neurologists should be proactive in assessing as amitriptyline, doxepin, the impact of underlying comorbidities on insomnia, particularly in the setting of mirtazapine, and trazodone; psychiatric conditions such as depression, sleep disorders such as circadian rhythm the antipsychotic quetiapine; antihistamine compounds disorders, and medical problems such as nocturia. such as doxylamine; medications available over-the-counter marketed as Continuum (Minneap Minn) 2017;23(4):1064–1092. sleep aids as single compounds or as a combination therapy with analgesics (acetaminophen INTRODUCTION ditions in medicine and has a signifi- or ibuprofen); and dietary Insomnia is pervasive in neurology prac- cant impact on populations treated in supplement sleep aids such as 1,2 chamomile, hops, kava kava, tice, but is often undiagnosed and neurology practices. Sleep difficulties melatonin, passionflower, tart untreated. Specific patient cohorts such often result from multiple etiologies and cherry juice, and valerian. * 2017 American Academy as older adults, patients who live in may require a multidisciplinary treat- of Neurology. nursing homes, and individuals with ment approach based on established underlying chronic comorbid medical, evaluation guidelines and evidence- neurologic, and psychiatric disorders based therapies.3 Recent evidence dem- are particularly at risk. These patients onstrates that poor sleep is associated often present with difficulties falling with a wide range of negative health asleep and maintaining sleep and expe- outcomes and that poorer quality of rience significant daytime consequences life and medical, neurologic, and psy- such as fatigue, memory problems, and chiatric comorbidities disrupt sleep. poor psychosocial function. Given this bidirectionality, neurologists Chronic insomnia disorder is among should take measures to discuss sleep the most widely reported clinical con- problems and their impact on the 1064 ContinuumJournal.com August 2017 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINTS underlying neurologic disease and take Several classification systems offer h Recent evidence specific steps toward enhancing sleep criteria for insomnia nosologies and demonstrates that poor quantity and quality in their patients. specific insomnia phenotypes. Insom- sleep is associated with By doing so, the clinician may have a nia classification schemes are outlined a wide range of broader role in promoting wellness by the International Classification of negative health and bringing about improvements in Diseases, Tenth Revision (ICD-10) and outcomes and that some comorbid conditions as well. the Diagnostic and Statistical Manual poorer quality of life and of Mental Disorders, Fifth Edition medical, neurologic, DEFINITION OF INSOMNIA (DSM-5), which is the American Psy- and psychiatric Insomnia disorder refers to persistent chiatric Association’s 2013 update to its comorbidities disrupt difficulties falling asleep, maintaining classification and diagnostic tool.6,7 sleep. sleep, or waking up earlier than habitual Both the ICD-10 and DSM-5 assimilate h Insomnia disorder refers rise time and is associated with impair- categorizations of key sleep disorders to persistent difficulties ment of daytime functioning despite including various insomnia subtypes. falling asleep, the opportunity for sufficient sleep The 2014 American Academy of Sleep maintaining sleep, or waking up earlier than duration.4 Although patients with in- Medicine (AASM) International Classi- habitual rise time and is somnia report the chronicity of wake- fication of Sleep Disorders, Third Edi- associated with fulness during the night, insomnia tion (ICSD-3) defines general criteria impairment of daytime disorder is conceptualized to represent for chronic insomnia disorder, reviewed functioning despite a 24-hour condition reflecting a state of in Table 8-1,aswellasshort-term the opportunity for 4 hyperarousal leading to both the night- insomnia disorder. The chronic and sufficient sleep time and daytime symptomatology.5 short-term insomnia disorder criteria duration. a TABLE 8-1 Diagnostic Criteria for Chronic Insomnia Disorder Criteria A through F are required for a diagnosis of chronic insomnia disorder A. The patient/family members/caregiver reports or observes one or more of the following 1. Difficulties with sleep initiation 2. Difficulties with sleep maintenance 3. Waking up earlier than desired with difficulties reinitiating sleep 4. Opposition to going to bed during habitual bedtime schedule 5. Difficulties sleeping without the intervention of the parent or caregiver B. The patient/patient’s parent/caregiver report or observe one or more of the following difficulties in relationship to the nighttime sleep difficulty 1. Malaise/fatigue 2. Impairment in concentration, attention, or memory 3. Impairment in domains of social function, fulfillment of family duties, or difficulties with occupational or academic performance 4. Disturbances in mood and/or irritability 5. Excessive daytime somnolence 6. Problems with behavioral function (eg, aggression, hyperactivity, impulsivity) 7. Impairment in motivation/energy/initiative 8. Proneness for accidents and/or errors 9. Concerns about or dissatisfaction with sleep quality Continued on page 1066 Continuum (Minneap Minn) 2017;23(4):1064–1092 ContinuumJournal.com 1065 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Chronic Insomnia Disorder a TABLE 8-1 Diagnostic Criteria for Chronic Insomnia Disorder Continued from page 1065 C. The reported sleep/wake difficulties cannot be otherwise explained by inadequate opportunity or inadequate circumstances for sleep (ie, the patients should have sufficient allotted time for sleep and environmental conditions are conducive for sleep [safe, dark, quiet, and comfortable]). D. Frequency criteria: The sleep difficulties and associated daytime symptoms must occur at a frequency of at least 3 times per week. E. Duration criteria: The sleep disturbance and the associated daytime symptoms must be present at least 3 months. F. The sleep/wake disturbance is not attributed to or explained by another underlying primary sleep disorder (such as obstructive sleep apnea, circadian rhythm sleep-wake disorder, or a motor disorder of sleep). Notes 1. Insomnia may be observed across all age groups. Opposition to going to bed on a proper schedule and difficulty sleeping without a parent or in the absence of a caregiver intervention is seen most commonly in children and older adults who require the supervision of a caretaker due to a significant disturbance in cognitive or functional impairment (eg, patients with underlying neurodegenerative diseases such as Alzheimer dementia). 2. A unique circumstance occurs when